caring ,sharing , devotion ,worship
DESCRIPTION
Caring ,Sharing , Devotion ,Worship. Significant Event - Using what we have. Significant Event. Definition:. “ any event that any member of the team considers to be significant in terms of the care of the patient and the conduct of the practice[organisation] ” (Pringle et al.; 1995). - PowerPoint PPT PresentationTRANSCRIPT
Caring ,Sharing ,Devotion ,Worship
Dr TA Taylor Wellington 2009
Significant Event - Using what we have
Significant Event
Definition:
Dr TA Taylor Wellington 2009
“ any event that any member of the team considers to be significant in terms of the care of the patient and the conduct of the practice[organisation] ” (Pringle et al.; 1995)
“ Doctors will become safe when they choose to become safe”
Five Years After To Err is Human – What have we Learned? Lucian Leap & Don Berwick. Jama.2005; 293 : 2384-2390
Dr TA Taylor Wellington 2009
Dr TA Taylor Wellington 2009
Significant Event
Definition
Our Definition: “ Any situation, event, process, attitude and/or behaviour that another person can learn from to improve the outcome.”
Dr TA Taylor Wellington 2009
“ any event that any member of the team considers to be significant in terms of the care of the patient and the conduct of the practice[organisation] ” (Pringle et al.; 1995
Socio-economic status
37% (160.000) people NZ Dep Index 9 – 10
58% ( 45.000) of All Maori in CM Decile 9 - 10
79 % ( 74.000)of All Pacific people in CM Decile 9 - 10
46% of 0 – 4 yr old in CM live in Decile 9 - 10
NZ Census 2001Dr TA Taylor Wellington 2009
Nurse
GP
Clinical Assistant
Receptionist
Patient Whanau
Dr TA Taylor Wellington 2009
Registered Population 120.000
Enrolled and Funded 87.000
Pacific People 40.000
Maori 14.000
Patients
Clinics
40 Reception staff
12 Clinics47 GP’s
45 Nurses9 Clinical Assistants
9 Management16 Admin Support
Dr TA Taylor Wellington 2009
New Zealand Trained Doctors 7
New Zealand Trained Doctors Pakeha 2
New Zealand Trained Doctors Asian 2
New Zealand Trained Doctors Pacific 3
IMG Maori 1
IMG 41 (87%)
Doctors from Multicultural and Diverse Backgrounds
Dr TA Taylor Wellington 2009
25 Doctors are Fellows of RNZCGP
20 Doctors are working towards it (GPEP1 and GPEP2)
1 Clinic ACC/ AMPA Accredited
56 Staff Achieved the CBMC Certificate
Culture of Quality
Dr TA Taylor Wellington 2009
Quality Pursuits - Cornerstone Accreditation
Knowledge Attitudes Behaviour
Lack of awareness
Lack of agreement with
evidence
External barriers
Volume of information
Uncertain interpretation
Environmental factors
Barriers to evidence uptake
Sources of behaviour change
Institutional factors
Unclear applicability
Access to resources
Lack of motivation of previous practice
In 2006 ~ 10 SE per quarter ( 3.3 per month)
In 2007 onwards ~ 50 SE per month ( 150 per quarter)
ETHC SE Reporting
Dr TA Taylor Wellington 2009
What Does this Mean ?
• Are we getting worse ?
• Does this increase our risk ? (professional, financial, other)
• Are our patients at more risk ?
Dr TA Taylor Wellington 2009
Definition: “Any activity or process that facilitates the transfer of
high quality evidence from research into effective changes in health policy, clinical practice, or products.”
“…combines the elements of research, education, quality improvement, and electronic systems development to create a seamless linkage between interventions that improve patient care and their routine implementation in daily clinical practice.”
Ann Emerg Med. 2007;49:355-363
Knowledge Translation
Dr TA Taylor Wellington 2009
Consequences
Likelihood Insignificant Minor Moderate Major Catastrophic
1 2 3 4 5
A (Almost certain)
H H E E E
B (Likely) M H H E E
C (Moderate) L M H E E
D (Unlikely) L L M H E
E (Rare) L L M H H
P CM
G
Identification – Documentation – Reflection Cycles
Challenges
• How do we engage our patients in developing safer environments ?
• Technological Advances at its best can only reflect human relationships
• Governance - Taking it Seriously
Pre-requisites Right culture
Right leadership
Right relationships
Right systems
Regular reflection on practice
Take Home Messages
Dr TA Taylor Wellington 2009
“ Doctors will become safe when they choose to become safe”
Five Years After To Err is Human – What have we Learned? Lucian Leap & Don Berwick. Jama.2005; 293 : 2384-2390
Waiting until doctors choose to become safe is not an option. Safety is first and foremost the patients prerogative.
We need to develop toxic environments for poor and unsafe practices – These are called Learning Environments.
Dr TA Taylor Wellington 2009
Thank You
